Abstract

The European Randomized Study of Screening for Prostate Cancer (ERSPC) showed a significant prostate cancer mortality reduction in the screening group of 21% after a median follow-up of 11 years, and of 29% in screened men when adjusted for selection bias. However, PSA screening is associated with considerable unfavorable effects. In the ERSPC screening group, cumulative incidence of prostate cancer was 7.4%, versus 5.1% in the control group. A proportion of the screen-detected tumors (10-56%) would never have led to clinical symptoms but these over-diagnosed cancers are frequently treated with associated risks of adverse effects. Furthermore, because of a long lead-time, estimated 5-12 years, men have to live longer with those effects. Two specific studies on quality of life after prostate cancer treatment have been performed for men participating in Rotterdam and Sweden. Pre-operatively 1-2% of the men were incontinent and 31-40% impotent. After 18-52 months 6-16% of the radical prostatectomy patients and 3% of the radiation therapy patients were incontinent. Six to 52 months after radical prostatectomy, 83-88% of pre-operatively potent men became impotent, compared with 42-66% of the men receiving radiation therapy. In this lecture the effects of screening strategies on prostate cancer mortality and quality of life will be quantified, using the well-validated MISCAN-model, developed by our institute, and hereby using results from the ERSPC. The implications of our results are that the benefit of PSA screening is diminished by loss of QALYs, that is dependent primarily on post-diagnosis long-term utility assumptions. Longer follow-up data from both the ERSPC and quality of life and cost-effectiveness analyses are essential for making universal recommendations regarding screening, but it is possible that limited testing of middle-aged men with relatively long intervals is a cost-effective public health policy.